APPLICATION FOR ADMISSION
THE EXECUTIVE PROGRAM
Master of
Science in Health Care Administration
RETURN TO:
Department of Health Care Administration
(210) 999-8107
(PLEASE TYPE
OR PRINT IN INK)
Name
__________________________________________________ Date of Birth _________________
Position/Title
______________________ How Long?
________Social Security # _____ - _____ - _____
Name
of Facility/Organization
____________________________________________________________
Address
of Facility/Organization
__________________________________________________________
__________________________________________________________
Telephone
(Office): Area Code__________
Number_________________Extension________
(FAX) : Area Code__________ Number_________________
(Home): Area Code __________
Number_________________
(e-mail address): _________________
Name
and Title of Immediate Supervisor
___________________________________________________
Work
setting:
_____Municipal/County
Hospital _____Rehabilitation
Facility
_____Health Maintenance
Organization _____Medical
Group Practice
_____Psychiatric/Mental
Health Facility (specify) ______________________________
_____Other (specify)
______________________________________________________
Supervisory
Responsibilities? _____Yes
_____No
How
did you hear about the Executive Program?
(Check all that apply)
_____Internet _____Career
Fair
_____Current
Student in Program _____Convention
Exhibit
_____Alumni _____Journal
_____Brochures/Direct
Mailing _____Other
(specify)
(over)
EDUCATION
Institution Degree,Diploma,Certificate Dates Attended
____________________ _________________________________ _______________
____________________ _________________________________ _______________
____________________ _________________________________ _______________
____________________ _________________________________ _______________
EMPLOYMENT
IN HEALTH CARE FACILITIES ONLY (past five years):
Facility/Organization Location Title Dates of Employment
_____________________ ___________________ _______________ __________
_____________________ ___________________ _______________ __________
_____________________ ___________________ _______________ __________
OTHER
THAN HEALTH CARE FACILITIES, IF APPLICABLE (past five years):
_____________________ ___________________ _______________ __________
_____________________ ___________________ _______________ __________
_____________________ ___________________ _______________ __________
MEMBERSHIPS
IN HEALTH-RELATED ORGANIZATIONS:
_______________________________________________ ________________________________
(Signature of Applicant) (Date
of Application)